For a healthy society, we have to act upstream

Ever wondered how Upstream got started?

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In this excerpt from A Healthy Society, Upstream founder Ryan Meili reflects on Upstream's genesis.

Michael Marmot has spoken about the need for “a social movement, based on evidence, to reduce inequalities in health.” Building on the ideas of the first edition of A Healthy Society, a group of friends came together in 2013 to form Upstream, a growing part of the Canadian version of the movement invoked by Marmot. Upstream is a national, non-partisan, non-profit organization that describes itself as “a movement to create a healthy society through evidence-based people-centred ideas.”

"The parable of the river is a sticky idea. Once you’ve heard it, it’s difficult to think about health, or any public policy, in the same reactive, downstream way you always have."

When I first started speaking publicly about Upstream, I was a bit sheepish about using the word “movement,” worried that it might seem rather grand for such a new start-up. But everywhere in Canada, I found more evidence that the movement was real. In the health field, among those in public policy, and increasingly in the general public, work is under way that demonstrates an appetite for and application of a new approach. People from all walks of life recognize the value of health as the primary goal of our political decisions and of the social determinants of health as the road map to reach that destination. Upstream is simply the naming and framing of that existing effort.

The work of Upstream breaks into three main parts: think tank, story shop, and community. The think tank brings together experts – academics, front-line workers, and people with lived experience of deficits in the determinants – to supply the evidence regarding which policy changes would have the biggest impact. Being solid in the evidence is essential to the credibility of the group and also to the viability of the programs to follow. But all the facts in the world won’t make a difference if they don’t also connect with our feelings. That’s where the story shop comes in.

"We could see parties across the political spectrum talking about how to address the social determinants of health, because it’s what people understand and demand."

By working with writers, photographers, animators, and other creative storytellers, Upstream takes the same approach as A Healthy Society, using stories of real people to illustrate the effect of bad policies and the possibilities of good ones. These stories are then shared as part of specific issue campaigns, such as Poverty Costs, and online via Facebook and Twitter. By connecting evidence and emotion, head and heart, Upstream can build a community of individuals and organizations, both in person and online, who can bring the social determinants of health into its own conversations and campaigns.

A stream doesn’t change the landscape overnight, and neither will Upstream change the political landscape overnight. But the parable of the river is a sticky idea. Once you’ve heard it, it’s difficult to think about health, or any public policy, in the same reactive, downstream way you always have. As these ideas are discussed, as the rinse-and-repeat cycle persists, they will move from the margins to the mainstream. Eventually, we could see parties across the political spectrum talking about how to address the social determinants of health, because it’s what people understand and demand. We’ve seen this starting to happen, with media references to the determinants and the increasingly frequent use of “upstream” as shorthand for early intervention and forethought. Over time, this concept can act as a social vaccine, the kind of good idea that, when integrated into our thinking, protects us against bad ones.

As Rudolf Virchow wrote, “It is the curse of humanity that it learns to tolerate even the most horrible situations by habituation. Physicians are the natural attorneys of the poor, and the social problems should largely be solved by them.” This clearly gives greater influence to doc- tors than is warranted; it is by no means the role of one profession to determine what will improve the lives of those most in need. The advo- cacy described here is extremely important, but there is always the risk that, because physicians and other health care providers occupy such a privileged position in society, power imbalances will be perpetuated rather than challenged.

"This concept can act as a social vaccine."

But Virchow’s remark does shine a light on the fact that doctors see suffering every day and are trained to identify and remedy it. If they remain diligent, they can resist becoming inured to its inevitability. So long as the goal remains real improvement in the circumstances of the people whom they serve, including greater power and autonomy to determine those circumstances, there is much to celebrate in the new approach to health and advocacy. The renewed focus on health for all, led by trusted voices among the people whose work it is to fight ill- ness, bodes well for politics and for broader well-being in Canada.

Want to know the full story behind Upstream and this national movement toward better health? You can get the brand new edition of A Healthy Society here.